Document NG7ejoRoGXZLwox40EmRmyzeb

372 ' THE MEDICAL, JOURNAL OF' AUSTRALIA. -Ma y 9,1931. pedal Articles on Diagnosis. (Contributed by Bequest.) pling may he produced by quite other agencies in childhood.'' Conversely, the absence of stippling does not exclude !. plumbism. There is no characteristic alteration in the white cells. This may be a negative sign of slight value. (i) In regard to the Bnrtonian blue line, two essentials XLIV. are required: Sufficient circulating lead in the blood and a septic dental factor--no blue line is found in the absence CHRONIC LEAD POISONING. of dental sepsis. The line occurs as a row of minute blueblack dots just at the gum margin. It is best shown by inserting a stiff white card between tooth and gum, raising Ch r o mic lead poisoning is the result of the absorption the gum margin--Gihson's test. The blue line is not of small quantities of lead for a continued period, as necessarily confined to the incisor teeth, it may occur at opposed to acute lead poisoning, the result of taking a the gum edge of any septic tooth. I large quantity, for example, of the acetate, in one dose. (i) Lead in the urine. This can be detected only by an Many of the manifestations of chronic lead poisoning may : expert chemist in a first class chemical laboratory. At i be so abrupt in their appearance that they are called acute, least one litre of urine is required and it must he col but the underlying pathological process is a long continued ` lected so as to be free from lead contamination, for one. ' - example, lead foil on- cork or bottle. A clear pickle bottle There are two forms of lead poisoning seen in Australia: or, better still, a winchester is washed first with tap water, (i) Of adults, an. industrial disease; (ii) of children, a then with distilled water and finally with 20% hydrochloric house disease. acid in distilled water. Decomposition may be prevented The latter is almost entirely, so tar as is known at., present, confined to north-eastern Australia, from the northern rivers of New South Wales up. The former is' seen in certain industrial centres, where such operations' as lead refining, enamelling and battery making are in ' progress. It is also seen to a less degree nowadays among painters, printers and plumbers. Certain features are common to both diseases. by adding formalin, 20 cubic centimetres to the litre. Lead present above 0-05 milligramme per litre is regarded as ` pathological. The presence of lead In the urine does no: necessarily prove that any lesion under consideration is due to lead poisoning, any more than a positive Wasser- mann reaction proves that an ulcer on the tongue is syphilitic and non-malignant. It does, however, indicate that lead, a tissue poison, is present in the body and is being -excreted by the kidneys. Some patients with Le a d Po is o n in g in Ch il d r e n . The forms of lead poisoning found among children are plumbism may show no lead in the urine and lead may be found in the urine of patients in whom no other manifestation can be found. held to be the simple paralytic, the cerebral and the minor `(fc) Albuminuria, usually unaccompanied by casts, is forms. ' ' common in all degrees of lead poisoning, from the mildest Certain features are common to all these forms: abortive forms to the most severe paralysis. The amount (a) The patients are usually over two years and under - varies from a faint cloud with salicyl-sulphonic acid to a eight years--the veranda age. heavy deposit of 0*5% Ksbach.' Actual renal damage to the .. (6) The sexes are equally affected. extent of inefficiency is rare during the initial stages. (c) There is an available source of lead, for example, The Simple Paralytic1 Form. powdering paint on walls, fences or railings. In the simple paralytic form the following muscles are (d) The means of transferring the lead to the mouth is affected. In the lower extremities the peronei and exten by nail biting, finger sucking or drop catching. sors of the foot may give rise to the common foot drop. (e) Usually there is a stage 'of preceding moderate ill In the upper extremities the extensors of the wrist, health, lack of appetite, listlessness and pallor. especially the extensor digitorum communis and extensor if) Colic consists of a sudden spasm of pain, "doubling up" and coming on without warning, unaccompanied by diarrhoea, but sometimes by vomiting, and localized mainly ' to the upper part of the abdomen. John Hunter described it as "dry bellyache" and the description still holds. The pulse rate falls even to 40 to the minute. Firm abdominal.' pressure relieves, not increases, the pain. Colic must be distinguished from (i) acute intestinal obstruction of organic origin, for example, volvulus; (ii) entero-spasm giving rise to a transitory obstruction; (iii) acute appendi citis, distinguished by a rise in temperature and increase in pulse rate;' (iv) simple dietetic upsets; (v) biliary and renal colic which are rare in childhood. The fact that in an attack of colic irregularities of the colon may be palpable often%adds to the difficulties of diagnosis. indicis may be affected so that the wrist can be extended if the fist is closed (Gower's sign). Involvement of the trunk ie rare, but paralysis of the diaphragm has been observed. Sometimes combinations of all forms of .paralysis occur, for example, upper and lower limbs have been occasionally paralysed at the same time. The features of the paralysis are as follows: Flaccidity . is present. The paralysis is slowly progressive. It is a neuritic paralysis, picking out nerves and not segments. The reaction of degeneration is present when paralysis is . complete. There is no sensory disturbance, apart from pain in affected muscles and on pressing nerve trunks. Usually complete recovery occurs, even after much wasting of muscle, but deformity, for example, talipes equinovarus, may persist requiring surgical treatment. Most 'striking of all, the paralysis is symmetrical. (a) Wasting, Especially of the muscles of the face, occurs, apart from actualjQ,ual-ysiSTni'd'of the subcutaneous This paralysis must be distinguished from: fat._Thn.jnfraerbita`UaHd buccinator muscles are specially ( ) Diseases of muscles--the myopathies. affected. \ ( ) Other forms of neuritis, such as alcoholic (very . (h) There are certain blood changes commonly seen In eases of plumbism, though they are not necessarily characteristic of this disease. A fall of erythrocytes to as low as 2,000,000 occurs and a greater proportional fall of hemoglobin, so that the colour index is as low as 0-6.. The red cells are altered. There may be poikilocytosis,. anisocytosis with a general diminution in size of the cells, rare in childhood); arsenical (also rare) in which sensory changes are prominent; syphilitic, rare and not usually symmetrical; and diphtheritic, though the dis tribution is rather different, and a history of sore throat or nasal discharge can always he elicited; acute infective polyneuritis, another rare disease, in which sensory changes are very obvious. loss of central hemoglobin so that the cell appears quoit- - (e) Spinal conditions: (i) Acute anterior poliomyelitis like, alteration in staining, either a general tendency to is distinguished by its acute onset in a previously healthy take the blue of the Jenner-Romanowsky stains rather child, the more asymmetrical distribution and the seg than the eosin,' that is, a polychromasia, and the classical mental rather than the neuritic manifestation, and finally stippling. The last is claimed to be characteristic of lead anaemia and by some the presence of more than 500 stippled 1 Dr. W. T, Nelson of the Commonwealth Scrum Laboratories cells per million is alleged to he pathognomonic of lead. Others are less dogmatic and hold that characteristic stip informs me that he is engaged on work which still further tends to cast doubt upon the specificity of suppling as a sign of- plumbism. N36945 DUP050314318 Hay 9,1931, THE MEDICAL JOURNAL OF AUSTRALIA. 573 by the fact that recovery does not tend to he complete. . fluid, distinguish it in the earlier stages, while in the (ii) Progressive muscular atrophy, disseminated sclerosis later the obvious progress to a fatal issue provides an and column diseases of the cord are rare at this age, and absolute, if late, distinction. Tuberculous meningitis is the distribution and nature of the paralysis are very different. rare in Queensland and Is extremely uncommon in children over two years of age. (d) Rheumatism, which has only a very superficial Epidemic Encephalitis.--Epidemic encephalitis may be resemblance. ushered in with slight or no rise in temperature, heaviness In most cases it is dangerously fallacious to use the results of treatment for purposes of diagnosis. It leads to arguing in a circle. Should, however, a patient with doubtful paralysis make a complete recovery when given rest in a zero position and treatment by magnesium sul phate and potassium iodide, it is often claimed that thiB supports the diagnosis of plumbism. and, above all, squint or other cranial nerve signs. Papillcedema is of the utmost rarity, and its presence is always enough to cast grave doubt on the diagnosis. The Neuro-Retinitis of Diabetes and Arterial Hyper tension.--In diabetes the condition is a neuro-retinitis, not a papillcedema, and other signs of the disease, for example, high blood pressure, albuminuria or glycosuria The Encephalopathic Form. will be present. The mechanism of the encephalopathic form is at present in dispute. The essential feature is an increase in cerebral pressure owing to either an excessive production or a diminished elimination of cerebro-spinal fluid, which is normal in character in our experience, though Aub and Holt describe an increase of ceils and globulin. Post mortem studies of the condition are lacking. Cerebral Syphilis.--Choked disc may be the only sign in basal cerebral syphilis. It may be combined headache and squint, and secondary optic atrophy may occur, as well as primary optic atrophy with no other frank manifestations of syphilis. The alteration in the cerebro-spinal fluid as regards Wassermann' reaction, cell count and globulin content must be always investigated. The excessive secretion may he due to increased activity Cerebral Tumour or Cerebral Abscess.--Differential diag of the eliorioid plexus, the result either of direct stimulus nosis from cerebral tumour or cerebral abscess may be by the circulating lead or indirectly through the products difficult in the absence of localizing signs. There may be of nervous tissue degeneration. a simple papillcedema, temporarily diminished by lumbar Little has been said as to deficient elimination in this puncture, a puncture which produces only normal cerebro matter, bnt the lead may well have a direct action on the spinal fluid under varying degrees of pressure. absorbing areas of the meninges. In any case the Sometimes only the course of the disease may be suf increased pressure is manifested by: Severe headache: ficient to establish the diagnosis, but occasionaiiy cerebral squint, due to paralysis of the external rectus muscle of._ tumours-' temporarily cease to progress, or even retrogress, one side; papillcedema; secondary optic atrophy and blind giving all the appearance of a cure. ness; convulsions of all degrees-of--severity. These may be In all cases of doubt the presence of some or all of the indistinguishable "from simple convulsions due to dietetic common features of lead poisoning may determine the or other causes, for example, onset of any acute illness. diagnosis. These may, however, be absent, as it is held They may be distinguished only by looking for possible that the encephalic form of lead poisoning is a manifesta sources of lead absorption; history of pallor, loss of tion of rapid intake of relatively large quantities. Radi appetite and headaches; blue line and blood changes; ography of the skull and even ventriculography may be squint, papilhedema and greatly increased cerebro-spinal necessary to distinguish these conditions. pressure on lumbar puncture. Of these the possible sources of lead absorption and a history of pallor et cetera Minor Forms. alone may call the parents' attention to the condition. Breinl and Young, in Animals of Tropical Medicine and Rarely is there sufficient disturbance of vision to attract Pathology, described minor forms of lead poisoning as attention, unless the condition has been a long time in follows; existence, by which time the damage may be great and irreparable. The headache is usually severe and frontal and continu ous. It may be sufficient to change a bright child into a very dull one, who will sit holding his head and dreading to be disturbed. The relief of the headache by lumbar puncture is very striking. Squint may be transitory, but is usually constant. Chil dren seldom complain of diplopia--the image of the squint ing, eye is neglected and nothing is said. The paralysis is practically always of the external rectus; it may be bilateral, but is more commonly unilateral and disappears rapidly after lumbar puncture. Papillcedema is a simple papillcedema, quite distinct from the hypertensive retinitis seen in advanced arterio-sclerosis. The swelling may be great, with comparatively little inter-.. fsrence with vision, up to 10. diopters. Similarly, if the pressure is relieved by ' lumbar puncture, the swelling rapidly subsides until the pressure- has been brought down to normal and remains there. A papillcedema of 10 diopters has been known to recover completely with such treatment alone. Should there follow failure to treat the papillcedema (a neglected swelling of much less will cause atrophy and blindness) the discs assume the typical chalk white colour, The'cases may be classed according to the severity of the symptoms. The very early cases have no definite symptom. Parents complain of a change in the character of the children within the last few years; whilst previously they have been normal and well behaved, lately they have become peevish and fretful, were very restless at night, and had lost their appetite completely. As a rule, only careful cross-questioning elicited the information that the child had been com: plaining of slight pains in the epigastrium and pains in the legs. The breath was often foul and now and again ulcera' tion was noticed in the mouth. According to the parents' statements the children were flushed in their faces and appeared feverish. All the symptoms referred to are very definite and may be considered as the commencement of any infectious disease. Even in these early cases lead can be found iu tile urine, often in appreciable quantities, and without the chemical analysis the correct diagnosis would he very ., difficult. In cases of slightly longer duration the pains in the abdomen, intermittent at first, have become more con tinuous. Constipation is the rule, but in rare cases a history of intermittent diarrhrea is given. Vomiting is the vessels shrink and the retina grows pale. The outlook only very rarely observed. The pains in the calf or is now hopeless. Such cases of blindness have occurred the leg become more marked, the calf muscles are in a child treated three times for papillcedema; the fourth often so painful that the little patients cannot endure .attack was left too long. even the weight of the bedclothes, and at this stage Differential Diagnosis. the gait of the'child becomes affected. The Burtonian line was observed only in a small percentage of the Tubercttlous Meningitis.--In tuberculous meningitis the children. child is usually feverish and too ill to get about. The A continuous line is not often found in children, but child with lead papillcedema, on the other hand, is often the characteristic minute black spots occur round alert and lively and afebrile. Kernig's sign, head retrac teeth which are coated with a deposit of tartar, tion and, above all, the reactions of the cerebro-spinal , requiring the use of a hand lens for their diagnosis- DUP050314319 574 THE MEDICAL JOURNAL OF AUSTRALIA. Ma y 9, 1931. The symptoms in these children are mainly' those of 3. The presence of stippled .cells with other blood general ill health; there.is nothing definite, hut the mother, changes, such as changes in the shape or size of the red complains that the child is listless, has no appetite, will cells, polychromasia, reduction of haemoglobin to S0% or not play, cries without provocation and is losing weight.. less, and reduction of red cells below four and a halt' He may sleep hadly, enuresis is not uncommon and slight, million, with or without symptoms of lead poisoning. abdominal pain, not amounting to actual colic,. is often The symptoms of mild lead poisoning are taken as present. 'Headache is a very variable symptom. abdominal pain, constipation, headache, debility and tremor. On examination there is at first little to be found. The. child is pealty, pale and often flabby. He usually cries Severe Lead Poisoning in the Adult. at any manipulation, but no source oi pain or frank tenderness may be found in the limbs or abdomen. Some-" times tbere is evidence of mouth breathing, there may he a faint blue line on the gums of septic teeth and there may be a slight suspicion of wrist drop or foot drop. The patients with headache rarely have papilltedema. The symptoms are very similar to those described by Mathew in mild cases of industrial plumbism. Evidences of possible lead absorption are always present, and should be sought for diligently, even if the child's own home affords no supply; there may be a neighbour's, a fence on the way to school or, in one case, a bridge rail. Nail biting, finger sucking and drop catching (in wet weather) are the commonest methods of collection. The conditions which may be mistaken for minor plumbism are: Minor degrees of chronic sepsis--of teeth, sinus or tonsils; congenital syphilis; intestinal worms; chronic intestinal indigestion (John Thomson); thyreoid deficiency in mild degrees; coeliac disease; pink disease; acute leuchsemia. I have seen all these conditions ascribed to lead, some by myself, some by others. ---------- ---------- Diagnosis is. not made easier by the fact that congenital syphilis, thyreoid deficiency and possibly some throat affections'are greatly benefited by potassium iodide, .while-many patients with chronic indigestion are relieved of much sluggish bowel content by a short course of mag nesium sulphate. The only possible method of. avoiding mistakes is to keep all these possibilities^ as -weltas' lead"" absorption, in mind when exarplning-thershild with chronic ill health and to_use-every method of diagnosis before deciding on a'line of treatment. Colic-is very constant and has to be distinguished from: (i) Colic due to acute abdominal catastrophes, tor example, perforated viscus, acute intestinal obstruction, acute pancreatitis. (Ii) Biliary or renal colic, (iii) Root pains of spinal disease, (iv) Tabetic crises. The "jerks and gums" are as important in abdominal diagnosis today as in the past. The pulse is slow in lead colic and the other signs of lead poisoning are present. The general characteristics of paralysis are as in chil dren. The most common form is wrist-drop, owing to the frequency with which the extensor indicis and extensor commmis aiyitorum are affected. The interossei are also often paralysed at this stage. Next in order of frequency come the shoulder muscles, especially the deltoid, then those of the leg, especially the peronei. Least of all arc the muscles of the trunk, larynx and diaphragm. Acute anterior poliomyelitis is uncommon in adults and does not present the same difficulty in differentiation as it does in children. The chief resemblance is to the -other--toxis-neuTitides; -alcoholic neuritis being the most common. Though much the same groups of muscles are involved, the sensory changes are very prominent and the other almost constant signs of plumbism are lacking. Similarly, these signs will serve to differentiate it from such diseases of the nervous system as progressive mus cular atrophy, tabes, disseminated sclerosis and ihe -myopathies. Lead encephalopathy rarely takes the form seen in childhood; its usual manifestations are headache, delirium, mania, psychic depression, coma or convulsions. These, especially if associated with lesions of the cranial nerves, may simulate cerebral tumour, cerebro-spinal ' Le a d Po is o n in g in Ad u l t s . syphilis, cerebral htemorrhage, epilepsy, chronic alcoholism, ureemia, eclampsia and hysterical or neurasthenic Lead poisoning in adults is in many respects very similar conditions. to that, of children. There are certain differences: (i) The correct diagnosis is made only by finding on the Age, in that young workers are more affected than the one hand other signs and/or symptoms of plumbism or, on more elderly, (ii) Sex. Abortion is very common among the other, features opposed to it, for example, changes- pregnant women, while amenorrheea, dysmenorrhoea and in the spinal fluid. But it must also be constantly menorrhagia also occur. (Hi) Source of lead varies with remembered that some of these conditions, for example, the industry--in lead refineries from the dust, in battery' syphilis or alcoholism, may coexist with lead poisoning making from the fumes. and a cerebral haemorrhage is a perfectly possible end It is notable that whereas in the older trades lead result of lead arterio-sclerosis. poisoning has diminished through altered methods, for Even without any of the foregoing frank maniiestations, example, the linotype in printing and the cellulose spray there is in. almost every sufferer from plumbism, child or in carriage painting, new industries have arisen in which adult, a degree of dulness, sluggishness and inability to the risks are as great, if not greater, for example, rubber concentrate, often combined with restlessness and manufacture and accumulator making. In adults the irritability. greatest part, by far, of the poisoning takes place from inhaled lead as opposed to the apparently ingested lead Late Manifestations of Plumbism. of the child.- The relationship of nephritis and arterio-sclerosis to Mild Forms of Adult Plumbism. lead poisoning is still a matter of dispute, both in children and adults. The initial period of ill health, pallor, lassitude, wasting As regards adults. Lead poisoning is one ot .the few . and lack of appetite are common to both adult and child. etiological factors admitted by Ejshberg in his discussion The blood changes are the same in each. The blue line on the -causes of essential hypertension, while Badham in the adult is often as seen ip the child, a narrow blue. sump up the matter as follows: line, but where severe pyorrhoea is- present there may be:a broad blue band, five or six millimetres wide, extending back from the giim margin. Urinary changes occur similar to those in children. Our limited knowledge of the sequelce of lead poison ing is no greater than when Legge and Goadby wrote; "Unless it were "established that granular kidney nephritis were present in a worker before couimeuce- On the foregoing is based Badham's standard of diagnosis - - ment of lead employment, we think it would be useless .of mild forms, namely: to endeavour to prove that the condition was indepen- A definite sign of a lead intake determined by the dent of -lead, despite its comparative frequency as a presence of a blue line or. lead in the urine in an amount exceeding 0-06 milligramme per litre, together with one or other of the following signs' of intoxication; cause of death apart from employment." With tile present limited knowledge of the manner of onset of arterio-sclerosis and nephritis .among-lead 1. The presence of stippled red cells to the number of workers, it is impossible to determine the cause one! over 600 per million red cells, with no other blood changed origin, of such degenerative eUungus in u lead worker.- and with or without symptoms a lead poisoning. It is comforting to the physician to know that there 2, The presence of stippled cells in number less than 500 is a history of past colic or palsy in any individual per million red ceils, with symptoms of lead poisoning. adjudged to be affected by arterio-sclerosis and/'r .p-------- --------- n--- -- DU P050314320 Max 9,19a 1. THE MEDICAL JOUBNAL OF 'AUSTRALIA. 375 nephritis caused by his work, "but it is probably fal lacious to think that such an easy means of selection . picks out those by_their trade from _those__who&e_ inherited vascular make-up leads to earfeAtegenerative ~ change. ...... BIBUCGBAFHY. The following authorities have been consulted: Legge and Goadby; "Lead Poisoning and Lead Absorp tion," 1912. Auh, Fairhall, Minot and Reznikoff: "Lead Poisoning," h'eiiictne Monographs, Volume VII, 1926. . Breinl and Young: "The Occurrence of Lead Poisoning amongst North Queensland Children," Annals of Tropical Medicine and Parasitology, Volume VIII. C. Badham: "Studies in Industrial Hygiene," Number 7, "Lead Poisoning," being part of the "Report of the Director 61 Public Health, New South Wales," 1925. "The Excretion of Lead and Blood Changes in Workers Exposed to Lead," "Report of the Division of Industrial Hygiene, Commonwealth Department of Health,'' Th e Me d ic a l Jo u r n a l o f Au s t r a l ia , February 16, 1927. fit. Fishberg: "Nephritis and Hypertension," I960. J. Lockhart Gibson, A. Jefferis Turu.er and other members of the staff of the Hospital for Sick Children, Brisbane: "Proceedings of the Australasian Medical Congress," 1892. J, Lockhart Gibson: "Ocular Plumbism," 1922. . L. Emmet Holt: "Diseases of Infancy and Childhood." , ' S. F, Mc Do n a l d , M.D., M.R.C.P., Honorary Physician, Hospital for Sick Children, Brisbane. 'Btitisi) ^epical association 3i2etos. SCIENTIFIC. A me e t in g o f t h e Vic t o r ia n Br a n c h o f t h e Br it is h Me d ic a l As s o c ia t io n was held at the Medical Society Hail, East Melbourne, on November 12, 1930, Dr . R. G. Mc Ph e e , the President, in the chair. Obstetric Abnormalities. Pr o f es s o r J. C. Win p e y e r read a paper entitled: "The Diagnosis and Treatment of Some Common Obstetric Abnormalities" (see page 551). Du. Fr a n k Ny u l a s y expressed high appreciation of Professor Windeyer's extremely interesting and instructive address, with its fine illustrations, and then said he would .confine his remarks to but one of the many topics dealt with, . namely, the occipito-posterior presentation. To begin with, he would remind members of the extraordinary differences of opinion and practice to be met with among leading authorities on this familiar subject. ~ For instance. Professor Hastings Tweedie, a past master of the RotundaTTirthe-third edition of his. text-book_slatefL that with the os fully dilated and the membranes" ruptured he made no attempt in delayed cases to turn the occiput forward either by the hand or the forceps, but "attended to the. common cause of failure of flexion, namely, uterine inertia." This was treated with a mixture of chloral and opium, or morphine given hypodermically. When the patient awoke, vigorous pains came on and the head frequently rotated to the front and was delivered spon taneously. Tweedie said: "If the head does not rotate, it does not matter much; put on forceps and pull it out slowly and carefully." Dr. FitzGihhon,- another ex-master of the Rotunda, expressed similar views. Thus he said: "If at the beginning of labour the head is still above the pelvic brim, efforts may be made to change it into the nearest oceipito-anterior position. This is most difficult and not necessary." During the second stage, if the occiput had rotated into the hollow of the sacrum, pressing on the fundus and encouraging the patient to bear down would push the head forward and complete delivery in quite a number Of cases. If it failed after a reasonable trial, delivery was completed ... ..... Professor Whitridge Williams, perhaps the most .famous of the American obstetricians, said that in a small propor tion- of-eases manual rotation could not be effected and it then became necessary to apply forceps with the occiput still posterior. Downward traction was then made till the head impinged on the pelvic floor; the occiput was then slowly rotated to a transverse and then to an oblique anterior diameter. The forceps were now taken off, reapplied and delivery effected. Dr. Nyulasy remarked that Professor Windeyer had ignored the question of forceps rotation and he quoted with significant approval a recent paper by Dr. Douglas Miller, Physician to the Edinburgh Royal Maternity Hospital. In the, course of his very able paper Dr. Miller said that "forceps rotation for occipito posterior cases demanded a high degree of manipulative skill and should he attempted only by the expert." On the other hand, Robert Watson, of Belfast, after about thirty years' experience, in a letter to The British Medical Journal in Jane, 1930, wrote; "The mariteuvre is simplicity itself. There is no feat in obstetrics so essential in general practice, easier to -perform or more effective. Deep chloroform anesthesia, is desirable through out. You diagnose the position of the head, lay your blades on as squarely to its sides as possible, lock the instrument and keep it locked, then (in a pause between pains, and gently) push the fcetus back towards the uterus till its head feels free. Now, still gentle, you .give the forceps a half turn (like a key in a lock) and proceed to deliver.. The original'instruction--to bring the head down until it is fixed and then withdraw the reversed forceps and apply them again--is unnecessary. More, it may do harm. .Heads can revert too easily. Thus in all hut exceptional cases it is safer and easier not to unlock the forceps. The facility with which delivery can he effected with them in this manner is a shock to one's notions about the parts and the art, hut a salutary shock, for modern obstetrics tends to become paralysed with exuberant theory," In supporting Dr. Watson's method. Dr. D.' C. Williams, in the same journal, wrote: "I always use Kielland's. forceps, and with this instrument rotation of the occipitoposterior position is so easy that the presentation offers no more difficulty than the ordinary anterior presentation. It is hard to understand why Kielland's forceps has not taken the place of the axis traction forceps in this country ..." In his own practice, Dr. Nyulasy continued, he generally preferred manual rotation when interference was necessary, but in exceptional cases he had used forceps rotation with distinct advantage. Dr . B. Mil n e Su t h e r l a n d expressed his appreciation of Professor Windeyer's address. The professor had presented his subject in broad outline, omitting minute details, and it was evident that he had cultivated a sense of touch which was beyond the capacity of most practitioners. Referring to occipito-posterior positions, the presence of excessive liquor amnii or abdominal fat might make the -diagnosis of position exceedingly difficult. Failure to rotate was usually due to rotation through less than half a semi circle, the head tending to rotate back into the hollow of the sacrum. It was necessary to rotate through three-. quarters of a semicircle at least. Watcher's position was of great assistance only in getting the head through the brim into the pelvic canal; it' tended to contract the outlet, and the position should be changed to the lateral or the lithotomy as soon as the head was in the. canal. Not infrequently the head was found in the transverse position, and he considered that there was a definite danger in rotation by forceps. The process must be a careful operation with no degree of force. De . Fe l ix Me y e r expressed appreciation ,o the paper, both in its material and manner expressing .the author's wide experience and authority. Books were occasionally written by men who had the courage of . the opinions of others, and so contained shibboleths which had been handed down, from writer to writer. It could he learnt from Professor Windeyer's teaching of the' management of occipito-posterior positions that trauma should he reduced to a minimum. He considered that Professor Windeyer's treatment of this problem was most lucid and convincing. DUP050314321